Saturday, February 6, 2010

It's not nice to fool Mother Nature

When asked why they get a restrictive surgery, such as the sleeve, over a malabsorptive surgery such as RnY or a DS, many people point to the need to take vitamins and possible issues with malnutrition. Definitely, if you don't absorb everything you consume due to an intestinal bypass, your risks of problems caused by malnutrition go up. But that doesn't mean someone with a restrictive-only surgery has no chance of experiencing a problem brought on by not getting enough of certain nutrients.

In my own case, my issues have all been with protein.

My protein and albumin levels were adequate pre-op. Nothing to write home about, but at least within what is considered normal ranges. My protein was at 6.9 (range is 6.4 to 8.2) and my albumin was 3.7 (3.2 to 4.7). I also had Vitamin D in the toilet at 32 (normal range is 45 to 100) and issues with calcium and potassium due to taking HCTZ for high blood pressure.

I have been able to solve the issues with calcium, potassium and Vitamin D by a combination of a supplementation and getting off the HCTZ. But my protein levels have not been as cooperative.

At 7 weeks out, I was in the ER with a kidney stone the day after giving blood. I had also had a week of inadequate protein intake of around 53 g a day. As a result, my protein dropped to a scary 5.7 and my albumin was 2.9. But I figured it was all temporary. I'd recover from giving away a pint of my blood and I'd go back to the 70-90 g of protein a day that my program recommended, and I'd been getting prior to my bad week, and everything would be golden.

But it wasn't. At three months out, the rest of my labs had recovered from what I now think of as "The Blood Giving Incident," but protein was only up to 6.1, which is still out of range. Albumin was up a bit, to 3.6, now in range and basically at pre-op levels, but I wanted it to be closer to 4-something.

I should point out that I was consuming an average of 80 g a day of protein at this point. My exercise was no where near where it would be out when I started training for the Half-ironman. I was in the gym about 4-5 hours a week tops, in fact, for no more than 45 min. at a time. That is what my program recommends as a basic minimum.

Over the next year, I made a big effort to get in enough protein. As I increased my exercise, I upped my protein intake. I was at the point where I was getting 125-135 g a day on average while training about 7-11 hours a week for anywhere from an hour to four hours a day. This is definitely above average exercise, but it's nothing compared to a lot of endurance athletes who workout more like 15-20 hours a week and consume a lot less protein than I do. (Most endurance athletes are all about the carbs.)

Because I was doing everything I was supposed to, I figured that my yearly labs would be great. I was hoping that I could discontinue taking 2x the adult dose of multivitamin and drop down to a normal adult dose and cut the calcium supplements to 1000 mg a day as well. I was consuming 2000 calories a day, so I figured that I should be getting everything I need from food except some of the calcium.

Therefore, I was quite dismayed to get my labs back and to see that my protein was still 6.1. Albumin was up to 3.7, so it was above pre-op levels, but not where I wanted to be. The rest of my labs were good with everything in range. My cholesterol numbers were awesome, B12 and Vitamin D were at the high end of the range, PTH and calcium were good. Potassium, something I'd had trouble with due to the HCTZ, was good. But the rest of the numbers were just good, not great. Or at least they weren't good enough to consider dropping back on any of my supplements.

As for my protein levels, Dr. Awesome said I needed to consume more protein or cut back on my activity level. Well, the choice was taken away from me when I got injured. I dropped down to 2-3 hours of exercise a week and my intensity level dropped too. I keep my protein at the same level and figured I'd be golden.

In Jan, I wanted to give blood for my triathlon club's blood drive, so I got labs done again. And my protein level is still 6.1. My albumin has actually dropped to 3.5!

How can that be?! I think the answer is: It's not nice to fool with Mother Nature.

Our bodies are made up of complex systems that interact on every level. You can't cut out part of an organ and not expect there to be consequences. With a smaller stomach, I now have less intrinsic factor than I used to and less stomach acid (especially since I'm on Prilosec). Also, my stomach empties slightly faster than normal. I also have much less ghrelin, aka the hunger hormone. While most of this is not going to cause big problems, it's not like it won't have any impact at all.

For me, having less ghrelin has been a blessing as has having less stomach acid. My GERD is mostly gone, easily controlled by taking a PPI, and my hunger is slightly under normal levels. But it appears that having less Intrinsic factor and faster stomach emptying means that I am not absorbing as many nutrients out of my food as I was pre-op. That means I have to keep taking all my supplements and it also means I have to be extra careful about my protein intake.

I do eat smaller meals all through the day and I've gotten much better at slowing down my eating, though I know I could be better. (It's still a goal of mine to be the last person to finish eating and not the first person.) At least my chewing is good. I no longer inhale my food, but actually chew it as much as you are supposed to.

I have to admit, there are days my carbs go way too high at the expense of my protein. It's not as bad as pre-op, but it's still not good. My choices are to keep to my designated calorie level or to go over to get the protein in. In the past, I'd have stuck to the calorie level, thinking that, as long as I got in 100 g a day of protein, I would be fine, but now I eat the extra protein and deal with the extra calories.

With triathlon season gearing up and my injury toning down, I am starting to increase my exercise and hope to get back to my pre-injury levels. As a results, I think I need even more protein. I got in 141 g average a day in January and I am aiming to gradually increase that to 150 g a day. And I'm not cutting back on any of my supplements.

I am crossing my fingers that this will work and I can get my protein in range.
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